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As pain improved one exercise seem to set me back more than any other. That was the push-up. Since there was a pectoral injury, it is easy to see why push-ups and even dips would be painful.  Below is a push-up test for telling if there is an asymmetry or improper form in the push-up.

 

 

In the bottom of the push up position, I try to retract my scapulae to see how much play I have in the shoulders. I like to compare that to the other side. As you can see in this video there is slight rounding of my right shoulder. It might be hard to see, but I’m actively trying put the R shoulder in a good position at the bottom of the push-up.  I like to retract the scapulae and even think about pulling the scapulae down towards my back pocket.  

The pectorals are in a great position to keep us from retracting(bringing the shoulders together). Here is a picture to remind us how the pectorals can pull the shoulder forward.

As you can see the lower trap (on the second picture) on the other side of your body helps keep the shoulders from rounding forward. If the lower trap pulls, it stretches the chest muscles and puts them in a better position. Try squeezing your shoulder blades back and down right now . This is your lower trap. Can you feel the stretch in your chest? Can you feel your shoulders move back ? This is why I like to pull the scapulae back and down. If done right, keeping your shoulders in this retracted state, it will puts us in a better position for the push-up.

Now that we know we have a pectoral strain( see Anterior Shoulder Pain?? ), how do we treat a pectoral strain?  Before we get into fixing this strain it would be nice to know what factors lead to hurting it? What issues created the opportunity for injury? Having to do CrossFit has made me realize weaknesses in my own workout program that I wouldn’t have normally noticed with an average gym workout.  Here are some limitations that opened the door for a pectoral injury.

Lack of internal rotation– The pectorals are an internal rotator of the shoulder.  With limited IR comes an inability for the pectorals to pull through this range and possible compensation from the shoulder. My shoulder injury occurred on the right side. Here are the two sides next to each other with me trying really hard to keep my scapulae pulled in.

Lack of shoulder extension –  This may be the biggest problem.  The lack of extension sheds light that my pulling motion could be weak when it comes to trying any type of pull. The Latissimus Dorsi which helps with a pulling motion is the main area of weakness with this motion. However, another muscle that helps pull is the pectoral group of muscles. Again here is the Left vs. the Right. Both seem weak but would say R is more limited.

Poor pectoral development on the R side– Since there is a lack of IR and extension which the pectorals produce it is easy to see that my pectorals probably do not function as well on the R side. Would love to show you my amazing development in my pecs but I will spare you this and let you take my word for it. The pectoral development on the right is far less developed.

Poor overall strength for pulling motion– Also since I have not done a lot of pulling motions over my life time it is easy to see that pulling could overall be weak. Moreover, there may not be a good baseline of strict strength for trying some of the activities in CrossFit that one might encounter.  I believe before implementing plyometric type of pull up, it is important that there is enough foundation of strength. Making sure you can do enough strict exercises before moving to high speed movement during that exercise could be a good option. If you can’t do a strict muscle up I believe it is good to doubt how well you do a kipping pull up.

Looking at these factors it’s easy to see a perfect storm coming for my right shoulder. See my past post for my info on pectoral strains.

Why does the shoulder take so long to heal? How come tendinitis never seems to go away? Even as physical therapist, I believe I can increase the rate of healing pretty quickly. However, after experiencing tendinitis for myself, I now see some things just take time.  I never knew how much time it takes for tendons to heal.  I would like to review the healing response of a tendon once it is injured.

As I woke up, at the start of my tendinitis, my arm was much more sore than with a usual workout. It was then I realized that my shoulder had worked past fatigue and had created an inflammatory process. The first initial stage of healing for a tendon is the inflammation stage.   This is routine for any kind of injury and inflammation usually last 3-7 days. Throughout the entire week, most positions of moving my shoulder felt painful and sore.  Not much to do but rest in this phase. For more background on hurting your shoulder see Part 1 here. Anterior Shoulder pain??

My shoulder continued to be sore over the next 4-6 weeks. I tried everything from dry needling, cupping, Graston, self-massage, and stretching to alleviate the pain more quickly. Some of it helped, but the pain continued to be there no matter what I did.  Working out was doable but created soreness the next day.  Probably causing the tendon become more inflamed.  Being a physical therapist, I felt like I could work out without causing further injury or setbacks, so I continued to take it easy.  Although it was sore, I knew I was not causing any more damage.  However, some exercises I could not do like dips, rowing, and pull ups.  These exercises really did make my shoulder feel as though it was taking steps back in regards to healing. This stage of healing (4-6 weeks) is called repair. In this stage inflammation subsides and tenocystes and fibroblasts take over the role of formulating new collagen where the slight tearing occurred. This stage last for 2 months and a process of synthesizing and reabsorbing collagen along the areas of injury occurs.  The injured area is beginning to repair itself. This is where I believe a noticeable improvement in pain and soreness is seen and where I believe physical therapy can do the most good. This remodeling is occurring along normal use and so challenging the tendon may help. Remodeling a tendon can be a good thing over the course of time. Soft tissue work and strengthening of the tendon during this stage needs to be done in a safe manner but might allow the tendon to recover faster and stronger.

Remolding is the next phase and continues for months.  This remolding even once finished, does not make the original tendon as strong.  So lets turn to the biggest factor we can change. This is factor is prevention and like with most injuries we need to figure out how it got injured in the first place. This is where as a physical therapist, I hear from all sorts of clients every excuse in the world. If you have pain you didn’t do it right, that’s a fact!  I hear things like my form is good, the trainer is good and want hurt them, well they never had issues before, or my doctor said it was just arthritis and age. Pain is the bodies way of saying you did something wrong and I’m not doing this anymore until you fix it.  Pain is alerting you to move differently or it will continue to cause more pain until you listen. Don’t ignore it, fix it. This is where physical therapy can continue to help with identify poor movement, weakness, limited mobility, and poor form.

Anterior(front) shoulder pain part 2

There were a couple of test that were helpful for diagnosing pectoral tendinitis.  Some subjective complaints were reaching across the body and reaching behind for an object. Some other test that were helpful were resisted horizontal adduction as seen below. If you can’t tell I am trying to push the arm straight over to the side of the table.

The other tell tell sign was extending the shoulder behind you.  I came up with this test and it just might have been the most painful position besides the above test. Reach the shoulder back and place the hand on the hip like so. Apply resistance into your hip without allowing you shoulder to move.  If it is painful you might have a pectoral injury. As you can see it is much like a push up position.

 

Besides shoulder extension people will find active shoulder flexion to be painful as well.

Part 1 is found here Anterior Shoulder pain??